Last Name, First Name
Point of Contact Email Address:
Point of Contact Phone Number:
Street, City, Zip code
No. of Full-Time Infection Preventionists:
Today D-M-Y
1. The facility has an Emergency Preparedness Committee which meets on scheduled basis (at least quarterly) and has a process for implementing an Incident Command System (ICS).
Yes
In-Progress
Not Started
Not Applicable
2. An annual needs assessment for infectious agent response is completed.
Yes
In-Progress
Not Started
Not Applicable
3. Readiness plans incorporate High Consequence Infectious Disease (HCID) and have input from a multidisciplinary team of potentially affected hospital departments (including but not limited to Infectious Disease, Administration, Infection Prevention, Critical Care Units, Emergency Department, Lab, Environmental Services, Respiratory Therapy, Communications, Emergency Preparedness, Engineering and Security).
Yes
In-Progress
Not Started
Not Applicable
4. The facility has appointed a designated person for coordination of emergency preparedness activities and designated back-up (recommended three deep).
Yes
In-Progress
Not Started
Not Applicable
5. The facility has a schedule for training events and drills related to infectious agent response.
Yes
In-Progress
Not Started
Not Applicable
6. Resources and time are allotted for annual drills and retraining, as needed, to address observed gaps.
Yes
In-Progress
Not Started
Not Applicable
7. HCID readiness binder/resources are available for frontline staff at point of use.
Yes
In-Progress
Not Started
Not Applicable
8. Detailed, scalable plans have been developed to support 24 hours of consecutive clinical care for a patient with a suspected HCID.
Yes
In-Progress
Not Started
Not Applicable
9. Providers and nursing staff are available and trained to handle the suspected HCID patient's needs.
Yes
In-Progress
Not Started
Not Applicable
1. Signage is posted in the waiting room/entrance regarding self-reporting of recent travel and information is posted on respiratory hygiene/cough etiquette.
Yes
In-Progress
Not Started
Not Applicable
2. Standardized screening questions regarding HCID are within the electronic health record triage protocol (i.e. international travel, fever, rash, respiratory symptoms).
Yes
In-Progress
Not Started
Not Applicable
3. A process is in place to further evaluate for a potential HCID if screening questions are positive (i.e. algorithm, information on global outbreaks).
Yes
In-Progress
Not Started
Not Applicable
4. Suspicion of a potential HCID is immediately shared with the treating physician/provider, staff, supervisor, and Infection Preventionist (IP).
Yes
In-Progress
Not Started
Not Applicable
5. The facility has tested (i.e. drilled) the triage surveillance system to ensure effectiveness in rapid identification of potential HCID in emergency departments (ED), clinic, urgent care, or other points of entry.
Yes
In-Progress
Not Started
Not Applicable
6. The facility has a plan to place a dedicated staff member outside the potential HCID patient's room to oversee processes at all times (i.e. monitoring entry to room, ensuring policies adhered to).
Yes
In-Progress
Not Started
Not Applicable
1. The facility has a plan in place to ensure immediate appropriate isolation when HCID is suspected.
Yes
In-Progress
Not Started
Not Applicable
2. The facility has a current list of all rooms that meet Centers for Disease Control and Prevention (CDC) requirements for airborne infection isolation room (AIIR) capacity.
Yes
In-Progress
Not Started
Not Applicable
a. Number of AIIRs in the facility:
b. The AIIR list is updated annually.
Yes
In-Progress
Not Started
Not Applicable
c. The AIIR list is shared with frontline staff.
Yes
In-Progress
Not Started
Not Applicable
d. Frontline staff are educated on ensuring the AIIR is properly functioning.
Yes
In-Progress
Not Started
Not Applicable
3. The facility has a written policy in place to ensure that AIIR negative pressure airflow is checked and monitored according to CDC guidance prior to placing a patient in the AIIR.
Yes
In-Progress
Not Started
Not Applicable
4. The facility has a written policy in place to ensure that AIIR negative pressure airflow is checked and monitored according to CDC guidance daily while a patient requiring AIIR is occupying the room.
Yes
In-Progress
Not Started
Not Applicable
5. The route to isolation room is pre-planned and the room designation for suspected HCID patient placement pre-determined (i.e. AIIR, location, set-up).
Yes
In-Progress
Not Started
Not Applicable
6. A plan is in place for room preparation as able (i.e. remove unnecessary equipment)
Yes
In-Progress
Not Started
Not Applicable
7. Isolation signage (i.e. HCID full barrier) is readily available to immediately post on door indicating necessary personnel only and and personal protective equipment (PPE) requirements.
Yes
In-Progress
Not Started
Not Applicable
8. A plan is in place for management of patients with potential HCID presenting to on-site and off-site clinics or other outpatient areas.
Yes
In-Progress
Not Started
Not Applicable
9. A plan is in place for managing persons (i.e., family) accompanying the patient who is suspected of having an HCID.
Yes
In-Progress
Not Started
Not Applicable
1. The hospital has selected appropriate PPE for care of patients with potential HCID that is easily accessible including:
a. Level 1- (have available close to point of care in kits or on a cart)
Yes
In-Progress
Not Started
Not Applicable
b. Level 2- (have PPE list below stating where items can be found)
Yes
In-Progress
Not Started
Not Applicable
2. The hospital has at least a 24-hour supply of Level 1 HCID full barrier PPE in stock.
Yes
In-Progress
Not Started
Not Applicable
3. Donning and doffing checklist are readily available. Designated donning and doffing partner is utilized.
Yes
In-Progress
Not Started
Not Applicable
4. A designated area for donning and doffing is predetermined (i.e., hot zone, warm zone) and staff education provided.
Yes
In-Progress
Not Started
Not Applicable
5. If PAPRs are available, ensure batteries are charged and ready to use. Designate an individual who is responsible for battery maintenance on a routine basis.
Yes
In-Progress
Not Started
Not Applicable
6. A review of HCID PPE for comfort, design, ease of use, and size is completed.
Yes
In-Progress
Not Started
Not Applicable
7. Policies and procedures are in place for PPE breaches (i.e., tear in gown/PAPR failure).
Yes
In-Progress
Not Started
Not Applicable
1. Information and resources on various types of HCID (i.e., EVD, other VHF, SARS, MERS) is available to frontline staff.
Yes
In-Progress
Not Started
Not Applicable
2. Personnel expected to provide direct care for a patient with suspected HCID are appropriately trained for their roles (recommend competency-based training). Training includes donning and doffing of HCID PPE for the following personnel:
a. Physicians/Providers: Donning and Doffing PPE.
Yes
In-Progress
Not Started
Not Applicable
Date of most recent training event:
b. Nurses: Donning and Doffing PPE.
Yes
In-Progress
Not Started
Not Applicable
Date of most recent training event:
c. Lab: Donning and Doffing PPE.
Yes
In-Progress
Not Started
Not Applicable
Date of most recent training event:
d. Radiology: Donning and Doffing PPE.
Yes
In-Progress
Not Started
Not Applicable
Date of most recent training event:
e. Environmental Services: Donning and Doffing PPE.
Yes
In-Progress
Not Started
Not Applicable
Date of most recent training event:
3. Retraining and drills are conducted with all health care personnel on a scheduled basis.
Yes
In-Progress
Not Started
Not Applicable
a. Frequency of retraining and/or drills:
1. The hospital has designated persons (at least three deep) to receive Health Alert Network (HAN) alerts.
Yes
In-Progress
Not Started
Not Applicable
2. Plans are in place for distribution of HAN alerts (i.e., Infection Prevention, ED, Lab, EMS, clinics).
Yes
In-Progress
Not Started
Not Applicable
3. The facility has a process in place for contacting the Minnesota Department of Health (MDH) when concerns arise (i.e., determination for who will contact, when, and how).
Yes
In-Progress
Not Started
Not Applicable
4. The facility has a representative regularly attend the regional Health Care Coalition (HCC) meetings and has process for communication with the HCC, if necessary.
Yes
In-Progress
Not Started
Not Applicable
5. Plans and processes for routinely communicating with local public health agencies are in place.
Yes
In-Progress
Not Started
Not Applicable
7. A plan is in place for internal communication of a potential HCID patient (i.e., lab, radiology, security, etc.).
Yes
In-Progress
Not Started
Not Applicable
1. Detailed, scalable staffing plans have been developed to support 24 hours of consecutive clinical care; sufficient physician and nursing staff are available to handle suspected HCID patient care needs.
Yes
In-Progress
Not Started
Not Applicable
2. Staff training is provided.
Yes
In-Progress
Not Started
Not Applicable
a. Number of physicians/providers trained:
b. Number of nursing staff trained:
c. Number of lab staff trained:
d. Number of environmental service staff trained:
3. Types of specialty services which may need to be provided have been discussed and planned for (i.e., pediatrics, OB, etc.).
Yes
In-Progress
Not Started
Not Applicable
1. The diagnostic laboratory has policies and procedures related to potential HCID patient testing.
Yes
In-Progress
Not Started
Not Applicable
2. The facility routinely schedules and reviews a Biosafety Risk Assessment.
Yes
In-Progress
Not Started
Not Applicable
3. A posted phone number for MDH Public Health Laboratory (MDH PHL) is easily accessible to frontline staff.
Yes
In-Progress
Not Started
Not Applicable
4. There is a designated lab staff member (primary contact) who maintains active partnership and communication with MDH PHL. This person's role is to ensure timely access to current lab guidance documents, training opportunities, and other pertinent updates (i.e., this person is listed as a contact on the Minnesota Laboratory System (MLS) for their laboratory, and is part of the MLS listserv) and will also serve as a clinical liaison to the MDH PHL to provide insight and feedback from a clinical lab perspective.
Yes
In-Progress
Not Started
Not Applicable
1. The facility has a pre-made staff log sheet that can be immediately posted to track staff who have contact or provide care to a patient with a potential HCID.
Yes
In-Progress
Not Started
Not Applicable
2. There is a process for monitoring of staff potentially exposed to a HCID for recommended length of time.
Yes
In-Progress
Not Started
Not Applicable
3. There is a plan for psychosocial support for frontline staff and/or family.
Yes
In-Progress
Not Started
Not Applicable
1. The hospital maintains an active partnership with local ambulance service(s).
Yes
In-Progress
Not Started
Not Applicable
2. A plan is in place for transport of patients with a suspected HCID from ambulance into the frontline hospital (i.e., predetermined route to ED isolation room).
Yes
In-Progress
Not Started
Not Applicable
3. A process is in place for notification of ambulance services, police, fire, first responders as indicated (i.e., post-exposure).
Yes
In-Progress
Not Started
Not Applicable
1. Plans are in place for interfacility transfer/transport of a potential HCID patient.
Yes
In-Progress
Not Started
Not Applicable
2. Information on the process and persons to contact for transport of a patient with suspected HCID is available to frontline staff for reference at any time (i.e., nights/weekends).
Yes
In-Progress
Not Started
Not Applicable
1. Plans are in place regarding cleaning and disinfection of equipment and the environment used to care for a patient with suspected HCID.
Yes
In-Progress
Not Started
Not Applicable
2. Plans are in place for cleaning/disinfection of areas potentially exposed to HCID during patient transport (i.e., ambulance to ED, cleaning down hall after waste transported).
Yes
In-Progress
Not Started
Not Applicable
3. The hospital has appropriate plans in place to safely store and secure Category A infectious waste until rule out/confirmation of diagnosis, including liquid waste (i.e., vomit, urine).
Yes
In-Progress
Not Started
Not Applicable
4. The hospital has a plan in place for waste-management and transporting Category A infectious substances.
Yes
In-Progress
Not Started
Not Applicable
5. A plan is in place to collect and store Category A waste from ambulance services.
Yes
In-Progress
Not Started
Not Applicable
6. The hospital has exercised (e.g., table top drill) Category A waste management.
Yes
In-Progress
Not Started
Not Applicable
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